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Panel Amendment Form

Please complete the form below

Is this panel number for	Mortgages Mortgage & General Insurance General Insurance
Type of appointment	New contact New payment route
Do you require an E-Service disk	Yes No
Section 1 - Broker / Intermediary
Select type of intermediary	Accountant Builder Estate Agent Insurance Company Mortgage Broker Solicitor
Name of payment route(s)
Introducer/Contact name
Company Name
Address Line 1
Address Line 2
Address Line 3
Post Town
Post Code
Telephone/Ext
Fax number
E-mail address
Development Manager Name
Section 2 - Mortgage Regulation Permissions
Status	Appointed Representative Directly Authorised
Other status (i.e. offshore)
Company FSA Number
Principal FSA Number
Principal name
FSA Permissions. Advise	Yes No
FSA Permissions. Lifetime	Yes No Both
Insurance Regulation
Status	Appointed Representative Directly Authorised
FSA Permissions fully authorised to conclude	GI Sales GI Introduction only
I confirm that the company already has a panel relationship with HBOS	Yes No

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For the use of mortgage intermediaries and other professionals only.

For independent information on mortgages, visit the FSA website 'money made clear'.

If you do not have professional experience, you should not rely on the information contained in this communication. If you are a professional and you reproduce any part of the information contained in this communication, to be used with or to advise private clients, you must ensure it conforms to the Financial Services Authority's advising and selling rules.

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